Provider Demographics
NPI:1194886630
Name:SCANDIA FAMILY DENTAL PA
Entity type:Organization
Organization Name:SCANDIA FAMILY DENTAL PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:MICHELE
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:REVOIR
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:651-433-2655
Mailing Address - Street 1:21080 OLINDA TRAIL N
Mailing Address - Street 2:
Mailing Address - City:SCANDIA
Mailing Address - State:MN
Mailing Address - Zip Code:55073
Mailing Address - Country:US
Mailing Address - Phone:651-433-2655
Mailing Address - Fax:651-433-2655
Practice Address - Street 1:21080 OLINDA TRAIL N
Practice Address - Street 2:
Practice Address - City:SCANDIA
Practice Address - State:MN
Practice Address - Zip Code:55073
Practice Address - Country:US
Practice Address - Phone:651-433-2655
Practice Address - Fax:651-433-2655
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty